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Southlake chiropractor Tyce Hergert saw about 5,000 patients last year. It’s common for insurers to pay only half a claim for chiropractic care, he says. ‘In several instances, I’m losing money to see a patient.’

National health care reform and state legal battles have touched a nerve in a longstanding spine care controversy as doctors dispute where chiropractic care crosses the line into the practice of medicine.

Chiropractors hope a change outlined in the Affordable Care Act will make it easier for them to open their services to more patients and boost their insurance reimbursements. For employers and insurers, the changes mean that more of their health care dollars may go to cover chiropractic care.

Back pain is one of the most common reasons for missed work, according to the American Chiropractic Association. Americans spend more than $100 billion annually to treat spine disorders, with an estimated $14 billion in lost wages, according to statistics from Dallas-based Parker University, formerly known as Parker College of Chiropractic.

In North Texas, spine disorder treatment is a more than $1 billion industry. There are more than 5,200 licensed chiropractors in Texas including more than 1,150 in North Texas, according to the Texas Board of Chiropractic Examiners.

Chiropractic eschews drugs and surgery in favor of spinal and other manual manipulations of the body intended to restore normal nerve function. Most chiropractors also advise patients on exercise, nutrition, physical therapy, posture and sleep habits.

The American Medical Association has long opposed some aspects of chiropractic care, taking the position that it’s unscientific and potentially dangerous. At the state level, the Austin-based Texas Medical Association has challenged specific chiropractic procedures and chiropractors’ right to diagnose disease.

“We think there is a very, very definite public health issue involved,” said David Bragg, an Austin-based lawyer for the Texas Medical Association.

Gaining equal treatment

The Affordable Care Act could help level the playing field for chiropractors, said Tyce Hergert, doctor of chiropractic at Chiropractic Care Center of Southlake PC.

“That legislation has language that allows providers to get treated equally by insurance carriers and governmental entities (such as Medicare),” Hergert said.

The Affordable Care Act, sometimes referred to as Obamacare, contains a nondiscrimination clause that requires health exchanges to cover providers who have a state license to practice health care of any sort.

This provision, if left intact, could prevent insurance claims payers from limiting reimbursement for chiropractic services, Hergert said.

Hergert said it’s common for insurers to pay chiropractors less than half of a claim.

“The math just doesn’t work,” he said. “In several instances, I’m losing money to see the patient.”

From an insurance perspective, under the Affordable Care Act, services rendered by chiropractors that are considered essential health benefits — such as office visits and X-rays — cannot have an annual or lifetime dollar limit, said Dr. Dan McCoy, chief medical officer of Richardson-based Blue Cross and Blue Shield of Texas.

Before the Affordable Care Act, many Blue Cross Blue Shield policies had a $1,500 per year limit for those types of services. Under the Affordable Care Act, Blue Cross now limits patients to 35 office visits a year instead of the dollar maximum, McCoy said.

McCoy said it’s too soon to quantify the financial impact to Blue Cross and Blue Shield of Texas of that and other changes under the act.

In addition, muscle manipulation by a chiropractor previously was not considered an essential health benefit, McCoy said, so dollar maximums applied. That also changes in 2014.

“Plans that we will offer on the exchange will cover chiropractic care, including muscle manipulation,” McCoy said. “The same goes for some of our individual and small group plans that are sold outside of the exchange as well.”

The Affordable Care Act does not require essential health benefits coverage for large groups, or self funded groups, so all employers may not need to increase their benefits packages, McCoy said. However, coverage for individuals and small group plans do require essential health benefits coverage, he said.

The American Medical Association, which declined to comment for this article, has passed multiple resolutions seeking the repeal of the provider nondiscrimination clause, with the latest resolution being in June 2012. The resolution calls for “direct and grassroots lobbying” to the Secretary of Health and Human Services, congressional leaders and other agencies and politicians.

Stepping on doctors’ turf

The scope of chiropractors’ work is determined state-by-state, and that’s been a bone of contention in Texas for years.

The Texas Medical Association and the Texas Board of Chiropractic Examiners clash over where chiropractic work crosses the line into the practice of medicine.

One case centers on whether chiropractors may perform manipulation under anesthesia, whether they may perform electromyography needle biopsies, and whether they may diagnose disease, or whether those procedures should be reserved for licensed medical doctors.

The latest rulings in the case, which has wound through the courts for more than three years, have gone against the state chiropractic board on the issues of manipulation under anesthesia and electromyography needle biopsies, Bragg said. However, a state appeals court ruled that chiropractors can diagnose conditions related to the spine and muscle system and be within the scope of their practice, Bragg said. He said he will appeal the decision on diagnosing on the TMA’s behalf this month, and the Supreme Court will decide from there whether to consider the case.

Many people don’t know the difference between a chiropractor and a medical doctor in terms of their scope of practice, Bragg said. The potential for misdiagnosis is higher if a person goes only to a chiropractor, Bragg said.

A patient’s rights

Georgia chiropractor J.C. Smith, author of “The Medical War Against Chiropractors” published in 2011, says the AMA’s opposition to chiropractic is self-interested and motivated by money.

For mechanical back pain, which makes up 80 percent of back pain, manipulation and hands-on therapy work the best, Smith said.

“The problem is, the AMA has in effect created a monopoly, and we are a competitor, and they’ve done everything they could to diminish competition,” Smith said. “They’re not about better health care and lowering costs. They like the health care system the way it is.”

Chiropractic care aligns with a key goal of health care reform, which is to increase the number of Americans receiving preventive health care and wellness services, said Brian McAulay, a doctor of chiropractic and president of Dallas-based Parker University.

The nondiscrimination clause is important because it ensures the approximately 30 million currently uninsured Americans will be able to access chiropractic care, McAulay said.

“One of the things early on that President Obama talked about was bringing more access to wellness and preventive care,” he said. “Chiropractic at its core is prevention oriented. We support wellness that prevents serious diseases.”

The increasing demand that health reform triggers for chiropractic services will lead to enrollment increases at Parker University, McAulay said.

Parker has 877 students now and expects to increase enrollment to 2,500 students in the next five years through a combination of adding to its chiropractic base and broadening its degree and course offerings beyond chiropractic to business, health-focused tracks, including health care IT, radiologic technology and an MBA for health care students, McAuley said. He estimates that in 2017, 1,000 students will be studying chiropractic and the rest will be studying in other areas.

An increase in coverage of chiropractic care means employers will see less absenteeism in the short run and lower health care costs in the long run, McAuley said.

“For employers, it means your employees are going to have access to chiropractic, which means they are going to be healthier,” he said. “With back pain, for example, chiropractic is a very cost-effective way to get people back to work.”

Hergert sees it as a patient’s rights issue.

“The TMA wants to essentially be the gatekeeper and take away the patient’s right to choose,” he said.

Hergert estimates he would lose half of the approximately 5,000 patient visits to his office last year if he’s no longer allowed to diagnose because patients would have to see a medical doctor before visiting a chiropractor.

“It’s going to make every patient we see upset that they have to go through that,” Hergert said. “A lot of the patients we see are frustrated at the medical model. They’re not getting better. That’s why they come here.”

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